1 / 24

Tripod-BETA

Tripod-BETA. Incident Investigation and Analysis. WHAT IS TRIPOD BETA?. A methodology for incident analysis during an investigation ... combining concepts of hazard management and ... the Tripod theory of accident causation. HOW DOES TRIPOD-BETA WORK?.

petula
Télécharger la présentation

Tripod-BETA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Tripod-BETA Incident Investigation and Analysis

  2. WHAT IS TRIPOD BETA? A methodology for incident analysis during an investigation ... combining concepts of hazard management and ... the Tripod theory of accident causation

  3. HOW DOES TRIPOD-BETA WORK? The incident facts are built into a tree diagram showing ... • What happened ... • What hazard management barriers failed and • Why each barrier failed

  4. HOW DOES THE TREE WORK? Let’s walk through a simple incident introducing the terminology and logic that underpins Tripod-BETA

  5. THE INCIDENT • Location: an offshore platform • Incident: an operative coming off shift slips and falls in the shower room • Consequence: he hurts his back and is off work • In the past three months there have been two similar incidents

  6. INITIAL FINDINGS • The incident occurred at 1820 hours • The operative slipped on the wet floor • Cleaning staff are supposed to keep the shower room floor dry

  7. STARTING A TRIPOD-BETA TREE We start by identifying: • An EVENT - where a hazard and a target get together • A TARGET - a person or an object that was harmed • A HAZARD - the thing that did the harm

  8. Hazard Event Target HAZARD / EVENT / TARGET TRIO They are shown in a Tripod tree like this:

  9. HAZARD, EVENT AND TARGET In this incident: The HAZARD is: Wet floor (slipping hazard) The EVENT is: Operative falls in shower room The TARGET is: Operative

  10. Wet floor (slipping hazard) Operative falls in shower room Operative HAZARD, EVENT, THREAT DIAGRAM The Hazard, acting on the Target, resulted in the EVENT

  11. IS THE INVESTIGATION COMPLETE? Does this show full understanding? • Finding: The man must have been careless • Recommendation: He should take more care on a wet floor Or is there something more?

  12. WAS THE INCIDENT PREVENTABLE? • We know that a hazard management measure was in place • Cleaning staff were assigned to keep the floor dry • That ‘barrier’ to the incident failed

  13. Wet floor (slipping hazard) Failed Barrier Operative falls in shower room Operative FAILED BARRIER The BARRIER should have controlled the HAZARD:

  14. Wet floor (slipping hazard) Non-slip floor Floor drying Operative falls in shower room Operative INCIDENT MECHANISM We could identify other barriers such as non-slip floor which were not there; this would be depicted as a “missing barrier”. But, for simplicity, let us concentrate on the “failed barrier”, i.e. floor drying

  15. FURTHER INVESTIGATION What caused the barrier to fail? • The cleaner could not keep the floor dry ... • because the shower room was always congested between 1800 and 1900 hrs

  16. Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative ACTIVE FAILURE An Active Failure defeated the barrier: Active Failure Cleaner Unable to keep floor dry

  17. END OF INVESTIGATION? Is this the end of the investigation? • Finding: The cleaner was incompetent • Recommendation: Cleaner should be replaced or retrained Or is there still something more?

  18. FURTHER INVESTIGATION • We know that congestion was a factor that prompted the active failure • Telephones are only available for private calls up till 1900 hrs • The congestion is caused by day shift crew hurrying to call home

  19. THE FULL PICTURE Now we have the full picture: • The congestion is a ‘Precondition’ that influenced the cleaner’s task • Restriction on telephones is a ‘Latent Failure’ that created the precondition

  20. Wet floor (slipping hazard) Floor drying Operative falls in shower room Operative PRE-CONDITION Restriction on private phone calls Latent Failure Congestion 1800-1900 hrs. Pre-condition Cleaner Unable to keep floor dry Lat. Failure Pre-condition Active failure

  21. Latent Failure Pre-condition Active Failure Lat. Failure Pre-condition Active failure Failed Barrier TRIPOD THEORY OF ACCIDENT MANAGEMENT Fallible Management Decision

  22. RECOMMENDATIONS Action items should address: • The Failed Barrier ... to restore safe conditions on a temporary basis (provide extra cleaner between 1800 and 1900) • The Latent Failure ... to remove the underlying cause (extend the availability of shore telephone)

  23. CORRECTIVE ACTIONS • If the barriers have not been replaced you should question why operations have restarted • Actions to replace barriers are normally on site • Latent Failures are deep seated; do not expect to remove them tomorrow • Action to tackle latent failures are normally at management level

  24. TRIPOD-BETA: BENEFITS • Brings a structure to an investigation • Helps distinguish relevant facts • Makes causes and effects explicit • Encourages team discussion • Pictorial display assists analysis and communication • Model backed by research into accident causation • Simple data entry to speed analysis process • Reduces the report writing task

More Related